TITLE IV-E BSW CHILD WELFARE PROGRAM
COUNTY EMPLOYEE
BSW REFERENCE/SUPPORT FORM
(Agency Supervisor or Program Manager)
DATE:
________________________________
APPLICANT NAME:
________________________________
REFERENCE NAME:
________________________________
The above named individual is applying for acceptance into the Title IV-E BSW Child
Welfare Stipend Program for the academic year of Fall 2009 at CSU-Fresno. The
curriculum for this program is designed to educate and prepare individuals for a
beginning level of professional practice within the field of Public Child Welfare. We are
seeking individuals who possess a genuine and sincere interest in and commitment to
working with at risk children and families within the child welfare system. Because of the
challenging nature of this field of practice, it is vitally important that individuals
demonstrate the qualities and skills necessary to problem solve and meet the special
critical needs present in diverse populations. We are therefore seeking those candidates
who strongly represent and adhere to the principles reflected in the NASW Code of
Ethics to maintain the standards of the profession of Social Work.
This student has selected you as a source of reference. We are depending upon you to
provide us with the information to help us access this student’s suitability to meet the
expectations of this program. We strongly believe that it is unethical to admit an
applicant who is not committed to working with children and families, whose ability to
successfully complete the program is doubtful, or who is not suited for the professional
role of Child Welfare Worker. Your thoughtful evaluation of this student’s potential and
readiness for professional practice and specialization in the field of child welfare is very
important to us.
We thank you in advance for your assistance in this matter and ask you to please respond
to the following questions. If you need more space, you are welcome to expand your
responses on a separate sheet.
1.
How long and in what capacity have you known the applicant?
_____ years _____ months
2.
___________________________________
(Specify capacity: supervisor, program
manager, etc.)
Please explain what you consider to be the applicant’s major areas of strength as a
candidate for the specialization in child welfare practice?
3.
Please explain what you consider to be the applicant’s area of limitation(s) that
need to be strengthened to foster success in working with children and families?
4.
Using the following scale from 0 to 3, (0= below standard, 1= average, 2=
above average, and 3 = exceptional), please address the applicant’s capacity in
the following areas: (Please use the * symbol if you are unable to evaluate the
area based upon lack of opportunity).
0-3 or *of
unknown
Questions:
Demonstrates intellectual ability
Ability to respect and work with diverse populations
Sensitivity to the needs and feelings of others
Ability to establish positive working relationships with others
Demonstrates professional work habits
Commitment to values & ethics of the social work profession
Ability to be accountable for professional practice in working with others
Willingness to accept direction, recommendations, and/or supervision
Demonstrates a positive level of common sense/judgment
Demonstrates acceptable levels of emotional stability
Demonstrates ability to problem solve utilizing positive strategies
Ability to complete task/assignments in a timely manner
Ability to solicit help/assistance when needed
Ability to effectively communicate in writing
Ability to effectively communicate verbally
Applicants overall potential for child welfare social work
5.
Recommendation: (Please check one):
____
I support this candidate’s participation in the Title IV-E Program.
____
I do not support this candidate’s participation in the Title IV-E
Program.
6.
Additional Comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please Print Name of Reference: _________________________ Date: ____________
Signature of Reference: ____________________________________________________
Name of Agency: ________________________________________________________
Address: _______________________________________________________________
Title: ____________________________________ Phone #: _____________________
Email Address: __________________________________________________________
Special Note: Reference/Support Forms will not be accepted without a signature
and a date. The deadline date for submitting all relevant information is March 13,
2009.
Please ask the applicant’s county agency Director to complete the Agency Director
reference letter on behalf of the applicant.
Please place your letter in an enclosed envelope, seal the envelope and sign your
name across the seal and return the sealed letter to the applicant.
Thank you for your time and commitment to fostering quality in social work practice.
University of California, Berkeley
2.04